2019 Merit-based Incentive Payment System (MIPS)

Quality Performance Category Fact Sheet

For Individual MIPS Eligible Clinicians, Groups, and Virtual Groups

What is the Quality Payment Program?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable
Growth Rate (SGR) formula, which would have resulted in a significant cut to Medicare payment
rates for clinicians. MACRA requires CMS by law to implement an incentive program, referred to
as the Quality Payment Program (QPP), which provides two participation tracks for clinicians:

Updated 02/13/2019 1
Under MIPS there are four performance categories that could affect your future Medicare
payments. Each performance category is scored by itself and has a specific weight that is part
of the MIPS Final Score. The payment adjustment determined for each MIPS eligible clinician is
based on the MIPS Final Score. These are the performance category weights for the 2019
performance period:

These performance category weights are different for APM participants in MIPS who are scored
according to the APM scoring standard. Please review the Quality Performance Category
Scoring for Alternative Payment Models for more information on the APM scoring standard and
for information specific to your APM.
Just like in 2018, MIPS eligible clinicians, who are not APM participants scored under the APM
scoring standard, may participate in MIPS individually, as a group, or as a virtual group in Year
3 of the program (2019).

Participate as an individual Participate as a group Participate as a virtual group

MIPS eligible clinicians MIPS eligible clinicians MIPS eligible clinicians
participating as participating in a MIPS group participating in a MIPS virtual
individuals will have their will receive a payment group will receive a payment
payment adjustment based adjustment based on the adjustment based on the
on their individual group's performance. virtual group's performance.
performance.
Under MIPS, a group is a A virtual group can be made up
An individual is a single single TIN with 2 or more of solo practitioners and groups
clinician, identified by a MIPS eligible clinicians, as of 10 or fewer eligible clinicians
single National Provider identified by their NPIs, who who come together “virtually”
Identifier (NPI) number tied have reassigned their (no matter what specialty or
to a Taxpayer Identification Medicare billing rights to the location) to participate in MIPS
Number (TIN). TIN. for a performance year.
Please note that some clinicians participate in MIPS through a MIPS APM, which has separate
requirements and scoring standards, and may receive a payment adjustment based on those
standards. A comprehensive list of APMs is available as well as an array of resources in the

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Quality Payment Program resource library. Additionally, if you are a part of a MIPS APM, we
encourage you to work with your APM on program requirements.

New MIPS Terms

You’ll notice the use of new language that more accurately reflects how clinicians and
vendors interact with MIPS (i.e. Collection types, Submitter types, etc.). We’ve solicited and
listened to your feedback and finalized these new terms in order to implement the program
in a way that is understandable to participants and beneficiaries alike. The new terms
include:
• Collection Type - a set of quality measures with comparable specifications and data
completeness criteria including, as applicable: electronic clinical quality measures
(eCQMs); MIPS clinical quality measures (MIPS CQMs) (formerly referred to as
“Registry measures”); Qualified Clinical Data Registry (QCDR) measures; Medicare
Part B claims measures (only small practices); CMS Web Interface measures; the
CAHPS for MIPS survey measure; and administrative claims measures.
• Submitter Type - the MIPS eligible clinician, group, or third-party intermediary acting
on behalf of a MIPS eligible clinician or group, as applicable, that submits data on
measures and activities.
• Submission Type - the way the submitter type submits data to CMS, including, as
applicable: direct, log in and upload, log in and attest, Medicare Part B claims, and the
CMS Web Interface. There is no submission type for cost data because the data is
collected and calculated by CMS from administrative claims data submitted for
payment. purposes.

Why Focus on Quality?

Quality measures are tools that help us measure health care processes, outcomes, and patient
experiences of their care. Quality measures also help us link outcomes that relate to one or
more of these quality goals for health care:
• Effectiveness • Patient-Centered
• Safety • Equitable
• Efficiency • Timely
There are over 250 MIPS quality measures available for reporting in the 2019 performance
period of MIPS. This includes measures available through most MIPS collection types such as
eCQMs, MIPS CQMs, Medicare Part B claims measures (small practices only), CMS Web
Interface measures (registered groups of 25+), and the CAHPS for MIPS survey measure.

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If you’re a MIPS eligible clinician reporting through a QCDR, you can also report on approved
QCDR measures developed by the QCDRs. These additional measures are outside the 250+
MIPS quality measures finalized through rulemaking and provide quality measurement options
that may be more applicable to your practice and/or specialty.
If you’re in a MIPS APM, you’ll have a set of required quality measures that the APM will submit
for you.
The QPP has seven types of quality measures:
1. Process,
2. Structure,
3. Intermediate outcome,
4. Outcome,
5. Patient Reported Outcome,
6. Efficiency, or
7. Patient engagement & patient experience.
These seven types apply to all of the quality measures submitted for MIPS across any of the 7
collection types. More information on each measure type along with examples, are listed in the
chart below.

Quality Measures by Measure Type

Process measures
Process measures show what
doctors and other clinicians do
to maintain or improve the
health of healthy people or
those diagnosed with a given
condition or disease. These
measures usually show
generally accepted
recommendations for clinical
practice.
For example:
• The percentage of
people getting
preventive services
(such as mammograms
or immunizations).
Process measures can tell
consumers about the medical
Outcome measures
Outcome measures show
how a health care service or
intervention affects patients’
health status.
For example:
• The percentage of
patients who died
because of surgery
(surgical mortality
rates).
• The rate of surgical
complications or
hospital-acquired
infections.
Outcome measures may
seem to be the “gold
standard” in measuring
quality, but outcomes happen
for many reasons, some of
Structure measures
Structural measures give
consumers a sense of a
health care provider’s
capacity, systems, and
processes to provide high-
quality care.
For example:
• Utilizing electronic
support systems such
as a continuity of
care recall system or
a reminder system for
mammogram
screenings.
• Checking for the
availability of
diagnostics for
patient follow up and
comparisons.

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care they should get for a which clinicians don’t have
given condition or disease. control over.

Patient Engagement and Intermediate Outcome Efficiency measures

Patient Experience measures
Efficiency measures can be
measures
Intermediate outcome used to assess the
Patient engagement and measures assess a factor or variability of the cost of
patient experience measures short-term result that healthcare and to direct
use direct feedback from contributes to an ultimate efforts to make healthcare
patients and their caregivers outcome, such as having an more affordable.
about the experience of appropriate cholesterol level.
For example:
receiving care. The Over time, low cholesterol
information is usually collected helps protect against heart • Ordering cardiac
through surveys. disease. Under MIPS, imaging when it does
intermediate outcome not meet the
For example:
measures meet the outcome appropriate use
• Administering the measure criteria. criteria.
CAHPS for MIPS
For example: • Overusing
Survey.
neuroimaging in a
• Reducing blood
target patient
pressure in the short-
population (such as
term decreases the
patients with
risk of longer-term
headaches and a
outcomes such as
normal neurological
cardiac infarction or
exam).
stroke.
Patient-Reported Outcome measures
These measures are derived from outcomes reported by patients and can include any report
of a patient’s health condition, health behavior, or experience with healthcare that comes
directly from the patient without interpretation of the patient’s response by a clinician. These
are related to health-related quality of life, symptoms and symptom burden, etc.
For example:
• The average change in back pain following a Lumbar discectomy or Laminotomy is
measure based on the patient’s reported level of their back pain.
High priority measures
MIPS scoring policies emphasize and focus on high priority measures that impact
beneficiaries. High priority measures are measures that fall within these measure categories:
• Outcome (includes intermediate- • Patient experience
outcome and patient-reported outcome • Patient safety
measures) • Efficiency measures

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 • Appropriate use • Care coordination
• Opioid-related quality measures

New for 2019: we revised the definition of a high priority measure to include opioid-related
quality measures.
High-priority measures are not an additional measure type. All 7 quality measure types
(efficiency, intermediate outcome, outcome, patient -reported outcome, patient engagement
experience, process and structure) include high priority measures.
New in 2019: We are implementing an approach to incrementally remove process measures.
For this approach, prior to removal, consideration will be given, but not limited to:
• Whether the removal of the process measure impacts the number of measures available
for a specific specialty.
• Whether the measure addresses a priority area highlighted in the Measure Development
Plan
• Whether the measure promotes positive outcomes in patients.
• Considerations and evaluation of the measure’s performance data.
• Whether the measure is designated as high priority or not.
• Whether the measure has reached an extremely topped out status, within the 98th to
100th percentile range, due to the extremely high and unvarying performance where
meaningful distinctions and improvement in performance can no longer be made.

What Do I Have to Do for the Quality Performance Category in Year 3

(2019)?
Just like in 2018, the Quality performance category will continue to have a 12-month
performance period (January 1 – December 31, 2019). When you report a full year of quality
data, we get a more complete picture of your performance and you have a greater chance to
earn a higher MIPS Final Score.
You will also have the chance to increase your 2019 Quality performance category score based
on your rate of improvement from your Quality performance category score from Year 2 (2018)
of the program.
To meet the Quality performance category requirements a clinician, group, or virtual group has
to submit one of the following:
Six quality measures for the 12-month performance period. The six quality measures must
include at least 1 outcome measure or another high priority measure in the absence of an
applicable outcome measure.

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Select your measures from a defined specialty measure set. One of the measures must be an
outcome measure or another high-priority measure in the absence of an applicable outcome
measure. If the specialty measure set has fewer than 6 measures, you need to submit all
measures within that specialty set.
Submit all quality measures included in the CMS Web Interface, a collection type available to
registered groups and Virtual Groups with 25 or more eligible clinicians.
Review Appendix A for a summary of the 2018 and 2019 MIPS performance years Quality data
submission criteria for Individual Clinicians and Groups.
What Are the Ways I Can Collect Quality Data?
We urge eligible clinicians, groups, and virtual groups to review each data collection type
carefully and to choose what works best for them. Many collection types use third party
intermediaries which you need to establish agreements with and/or register for before the
performance period begins in order to utilize them.
New in 2019: We will aggregate quality measures collected through multiple collection types for
the 2019 performance period. If the same measure is collected via multiple collection types, the
one with the greatest number of measure achievement points will be selected for scoring.
However, CMS Web Interface measures cannot be scored with other collection types other than
the CMS approved survey vendor measure for CAHPS for MIPS and/or administrative claims
measures. Please review Appendix B for a scoring example of how this policy will be applied for
the 2019 performance period.

Collection Type How does it work?

Qualified Clinical Data
Registry (QCDR)
Measures
Can be used by individual
MIPS eligible clinicians,
groups, and virtual groups.
CMS-approved, QCDRs collect medical and/or clinical data to
track patients and disease. Each QCDR usually gives
customized instructions about how to submit data. For MIPS,
eligible clinicians who choose this option have to participate with
a QCDR that we’ve approved.
You can find approved QCDRs in the 2019 QCDR Qualified
Posting document in the Quality Payment Program resource
library. You can also find a list of the 2019 QCDR Measure
Specifications in the Quality Payment Program resource library.
Note: Beginning with the 2020 MIPS performance period, a
QCDR will be defined as an entity with clinical expertise in
medicine and quality measurement development that collects
medical or clinical data on behalf of a MIPS eligible clinician for
the purpose of patient and disease tracking to foster
improvement in the quality of care provided to patients. This
requires action on the part of the QCDR, not the MIPS

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Collection Type
MIPS Clinical Quality
Measures (MIPS CQMs)
(formerly referred to as
“Registry measures”)
Can be used by individual
MIPS eligible clinicians,
groups, and virtual groups.
Electronic Clinical
Quality Measures
(eCQMs)
Can be used by individual
MIPS eligible clinicians,
groups, and virtual groups.
Medicare Part B Claims
Measures
New in 2019: Can only be
used by small practices
participating in MIPS as
individual MIPS eligible
clinicians or as a group.
How does it work?
participant. You will want to continue to monitor if your QCDR
maintains their approved status for the MIPS program annually.
MIPS CQMs are collected by Qualified Registries and QCDRs
and are submitted (via the Direct, or Log-in and Upload
submission types) on behalf of MIPS eligible clinicians.
Eligible clinicians who choose this collection type will have to
participate with a Qualified Registry or QCDR that we’ve
approved. You will want to continue to monitor if your Qualified
Registry and/or QCDR maintains their approval status for the
MIPS program annually.
You can find:
Approved Qualified Registries in the 2019 Qualified Registries
Qualified Posting document in the Quality Payment Program
resource library, and
Approved QCDRs in the 2019 QCDR Qualified Posting
document in the Quality Payment Program resource library.
Clinicians submit data they’ve collected through their certified
EHR technology (CEHRT). Clinicians can do this themselves
(via the Log-in and Upload submission type) or by working with
a certified Health IT vendor, Qualified Registry or QCDR who
will submit the data for them (via the Log-in and Upload, or
Direct submission types).
Groups and virtual groups that collect data using multiple EHR
systems will need to aggregate their data before it’s submitted.
Note for 2019: If you submit eCQMs, you’ll need to use CEHRT
to collect the eCQM data. You must have 2015 Edition CEHRT
in place by December 31, 2019 and the 2015 CEHRT must be
used to generate your eCQM data for reporting.
New for 2019: This collection type is only available for small
practices who participate in MIPS as either individual MIPS
eligible clinicians, groups, or virtual groups.
Small practices pick measures and report through their routine
billing processes. If they choose this option, they’ll need to add
certain billing codes to claims filed for denominator eligible
patient encounters to show that the required quality action
occurred or that the denominator exclusion was met.
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Collection Type
CMS Web Interface
Measures
Can only be used by
groups and virtual groups
with 25 or more clinicians
and Medicare Shared
Savings Program (SSP)
ACOs reporting on behalf
of MIPS eligible clinicians.
CAHPS for MIPS Survey
Measures
Can only be used by
groups and virtual groups.
How does it work?
For the 2019 performance period, Medicare Part B claims must
be submitted and processed no later than 60 days following the
close of the performance period to be analyzed for the Quality
performance category. Please refer to the 2019 Claims Data
Submission Fact Sheet for additional information. .
This is a secure internet-based application that pre-registered
groups and virtual groups with 25 or more clinicians can use. A
sample of beneficiaries are identified for reporting and we
partially pre-populate the CMS Web Interface with claims data
from the group’s Medicare Part A and Part B beneficiaries
who’ve been assigned to the group. Then, the group adds the
rest of the clinical data for the pre-populated Medicare patients.
Reporting via the Web Interface requires that you submit data
for all measures in the application. If you don’t have any
beneficiaries that qualify for the sample, CMS will direct you to
select another collection type and submission type option for
submitting quality data.
Groups and virtual groups interested in reporting through the
CMS Web Interface need to register at qpp.cms.gov between
April 1, 2019 and July 1, 2019.
ACOs participating in the Medicare Shared Savings Program
(Shared Savings Program) or Next Generation program do not
need to register for CMS Web Interface quality reporting
because it is a requirement of these programs.
See Appendix G for a list of the 2019 CMS Web Interface
measures.
Note: The bonus for submitting additional high-priority
measures via the CMS Web Interface is discontinued beginning
with the 2019 performance period. Also, when scoring
measures across collection types, CMS Web Interface
measures cannot be scored with other collection types other
than the CMS approved survey vendor measure for CAHPS for
MIPS and/or administrative claims measures.
Groups and virtual groups interested in administering the
Consumer Assessment of Healthcare Providers and Systems
(CAHPS) for MIPS survey need to register via qpp.cms.gov
between April 1, 2019 and July 1, 2019.
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Collection Type How does it work?
Groups that choose to report their patient experience data via
the CAHPS for MIPS survey have to pick another collection type
and submission type to collect and submit their remaining
quality measures.
Groups must meet minimum sample sizes to administer the
CAHPS for MIPS survey. We’ll let groups know if they meet
minimum sample sizes after group registration closes and
assignment sampling finishes.
Certain specialties such as surgeons, anesthesiologists,
pathologists and radiologists that do not provide primary care
services may not have patients to whom the CAHPS for MIPS
survey could be issued and may therefore not be able to receive
any bonus points for patient experience.
Groups are responsible for the costs incurred by administering
the survey and have to contract with a CMS-approved survey
vendor to conduct the survey. A list of approved vendors will be
posted on the Quality Payment Program resource library.
The conditional list of 2019 CMS-Approved CAHPS for MIPS
survey vendors will be made publicly available.
New in 2019: A group that wishes to voluntarily elect to
participate in the CAHPS for MIPS survey measure must use a
survey vendor that is approved by CMS for the applicable
performance period to transmit survey measure data to us.
Administrative Claims The Quality performance category has 1 measure, the All-
Measure Cause Hospital Readmission measure, that’s evaluated by
administrative claims. Groups and virtual groups, with 16 or
more clinicians, are automatically subject to the All-Cause
Hospital Readmission measure if they meet the case minimum
of 200 patients for the measure. If the group or virtual group
falls below the case minimum, the All-Cause Hospital
Readmission measure won’t be calculated, and clinicians will
only be scored on the reported measures.
Please note that no data submission action is required for
administrative claims evaluation and that the All-Cause Hospital
Readmission measure is not a part of the APM Scoring
Standard and won’t be calculated for groups participating in a
Shared Savings Program ACO.

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Getting Started
Here are 5 steps to help you get started:
1. See if you’re a MIPS eligible clinician
You’re a MIPS eligible clinician or group if you’re 1 of the following clinician types who bills
more than $90,000 in Medicare Part B allowed charges for covered professional services,
provides covered professional services to more than 200 Part B-enrolled Medicare
beneficiaries and provides more than 200 covered professional services under the Physician
Fee Schedule (PFS)1:
• Physicians, which includes doctors of medicine, doctors of osteopathy (including
osteopathic practitioners), doctors of dental surgery, doctors of dental medicine, doctors of
podiatric medicine, doctors of optometry, and chiropractors
• Physician assistants (PAs)
• Nurse practitioners (NPs)
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Physical therapist Clinician types in
bold are newly
• Occupational therapist
added to the program
• Qualified speech-language pathologist
beginning in 2019.
• Qualified audiologist
• Clinical psychologist
• Registered dietitian or nutrition professionals
• In any clinician group that includes 1 of the professionals listed above
For the 2019 performance period, if you would like to find out if you are a MIPS eligible
clinician (either at the individual or group level), you can use the Participation Status Look-up
tool on qpp.cms.gov.
2. Choose your measures
There are more than 250 quality measures in MIPS; additionally, if you chose to work with a
QCDR, additional QCDR measures may be available for your choosing. You can start looking
at the measures to find what works best for you, your group, or virtual group. If you’re a group,
virtual group, or MIPS APM reporting via the CMS Web Interface, you are required to report
on the measures in the Web Interface application.
To meet Quality performance category requirements, you need to pick at least 6 quality
measures, including at least 1 outcome measure or a high priority measure or report on
a complete quality measure specialty or sub-specialty set.
In addition to the quality measures you submit, there is one administrative claims measure, the
All-Cause Hospital Readmissions Measure, that is automatically calculated by CMS based on

1This third element is new for 2019. For more information on it please review the 2019 MIPS Eligibility
Overview Fact Sheet.

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 Medicare claims that are submitted. This measure will be calculated for groups of 16 or more
clinicians if the case minimum of 200 patients is met.
New for 2019:
• We revised the definition of a high priority measure to include opioid-related quality
measures.
• You can choose to submit the same measure across different collection types to optimize
your achievement score for the measure.
• You can also choose measures across all of the collection types available to you in order
to find the measures most meaningful to your practice (for example, you can submit two
eCQMs and four Medicare Part B claims measures (if you’re a small practice) and the data
across both collection types can count towards your Quality performance category score)
3. Understand your quality measures
Once you’ve found the measures that work for you, you’ll need to review each of your selected
measure’s specifications. Measure specifications describe each measure and outline their
elements, reporting frequency, corresponding codes, and more.
Each collection type has its own measure specifications, which can be found in the Quality
Payment Program resource library.
4. Collect your data
You should start data collection on January 1, 2019 to meet data completeness requirements
and to increase your opportunity to receive a higher Quality performance category score. For
the Quality Performance Category, you’ll need to report on 12 months of quality data for the
2019 performance period (January 1, 2019 – December 31, 2019).
2019 Collection Types Available According to Reporting Level

Individuals Groups

•eCQMs •eCQMs
•MIPS CQMs •MIPS CQMs
•QCDR Measures •QCDR Measures
•Medicare Part B Claims Measures •Medicare Part B Claims Measures
(small practices only) (small practices only)
•CMS Web Interface Measures
•CAHPS for MIPS Survey Measure
•Administrative Claims Measure

If you’re participating in a MIPS APM, you should work with your APM entity on timelines and
required activities for the 2019 performance period.
5. Submit your 2019 data
We’ll assess your performance on the data you submit.

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For the Medicare Part B claims submission type, which only small practices can use, we
receive quality data when claims are submitted for payment. Please note that your Medicare
Part B claims measures for the 2019 performance period must be processed by your Medicare
Administrative Contractor (MAC) no later than 60 days following the close of the performance
period to be analyzed.
For the Direct, Log-in and Upload, and CMS Web Interface submission types, the data
submission period will begin on January 2, 2020, and will end no later than March 31,
2020.
You’ll be able to find a submission timeline, that includes due dates, on qpp.cms.gov. You can
also review your performance feedback on quality data submitted via claims by logging into
qpp.cms.gov. This feedback will be updated on a monthly basis.
Wondering which submission types include QCDRs, Qualified Registries, and EHRs? The
below chart outlines the submission types and how they work.
Submission Type How does it work?
Authorized third-party intermediaries (such as
Direct
QCDRs, Qualified Registries, and EHR vendors)
can perform a direct submission, transmitting data
through a computer-to-computer interaction, such
as an API.
Individual clinicians, groups, virtual groups, and
Log-in and Upload
third-party intermediaries can login and upload
quality measure data in an approved file format on
qpp.cms.gov.
The log-in and attest submission type is not an
Log-in and Attest
option for submitting Quality performance category
data.
Individuals, groups and virtual groups that are small
Medicare Part B Claims
practices can submit their quality measures via
Medicare Part B Claims throughout the performance
period.
CMS Web Interface Registered groups and virtual groups, with 25 or
more clinicians, can submit their quality measures
through the CMS Web Interface.

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What is Quality Scoring?
For the 2019 performance period:
The weight of the Quality performance category is 45% of your MIPS final score.
Quality measures submitted for the 2019 performance period will receive
between 1 and 10 points as measure achievement points. Quality measures fall
into one of three categories for scoring:
• The measure meets the data completeness criteria, has a benchmark, and
the volume of cases is sufficient (> 20 cases for most measures).
o These measures continue to receive between 3 to 10 points based
on performance compared to the benchmark.
• The measure meets the data completeness criteria but either (1) doesn’t have a
benchmark and/or (2) the volume of cases you’ve submitted is insufficient (<20 cases for
most measures).
o These measures continue to receive 3 measure achievement points.*

• The measure doesn’t meet the data completeness criteria, which varies by collection type
(see Appendix C for a summary of the data completeness
requirements by Collection Type). Note: Beginning with the
o These measures receive 1 point, except for small practices 2020 MIPS performance
which would continue to receive 3 measure achievement period, MIPS eligible
points.* clinicians other than small
*These measure achievement points scoring policies would not apply to practices will receive zero
CMS Web Interface measures and administrative claims based measure achievement
measures. points for measures that
don’t meet data
Are there any other exceptions to these scoring policies? completeness criteria. Small
We are continuing the topped-out measure cycle where we specify practices will continue to
topped-out measures for each performance period. These measures are receive 3 points.
capped at 7 points each, and in 2019, they include, but are not limited to:
1. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation
Cephalosporin. (Quality Measure ID: 21)
2. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL
Patients). (Quality Measure ID: 23)
3. Image Confirmation of Successful Excision of Image-Localized Breast Lesion. (Quality
Measure ID: 262)
4. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy.
(Quality Measure ID: 52)
To identify if a measure is topped out, visit the 2019 Quality Benchmarks file, which can be
found in the Quality Payment Program resource library.

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Note: QCDR measures are excluded from the topped-out measure lifecycle and special scoring
policies. If the QCDR measure is identified as topped-out during the self-nomination process, it
may not be approved for the applicable performance period.
New in 2019: Extremely Topped-Out Measures. A measure is extremely topped out when the
average mean performance is within the 98th to 100th percentile range. These measures can
be proposed for removal in the next rule-making cycle and are not subject to the 4-year lifecycle
that applies to other topped-out measures. To identify if a measure is extremely topped out, visit
the 2019 Quality Benchmarks file, which can be found in the Quality Payment Program resource
library.
You can also earn bonus points based on improvement at the Quality performance category
level from one year to the next.
National Benchmarks
What are benchmarks?
When you submit measures for the QPP, each measure is assessed against its benchmark to
determine how many points the measure earns. We establish Quality performance benchmarks
either (1) prior to the reporting period for which they apply (these historical benchmarks are
based off of data from two years prior) or (2) from data submitted for that performance period
(these performance period benchmarks for the 2019 performance period will be calculated from
2019 data submitted during the data submission period, that is why they’re not available before
the start of the performance period).
Quality benchmarks for the MIPS CQMs, QCDR Measures, Medicare Part B claims measures,
and eCQMs collection types are established using historical data that’s collected 2 years before
the performance period. The 2019 Quality benchmarks were established using 2017 MIPS
performance data.
The CAHPS for MIPS benchmarks for Performance Year 2019 have not been established yet
because a revised survey was used for Performance Year 2018 and therefore sufficient
historical data are not available. However, benchmarks for Performance Year 2019 will be
calculated in the Spring of 2020 using performance period data for each summary survey
measure (SSM).
For the CMS Web Interface quality measures, benchmarks are the same as those used for the
Medicare Shared Savings Program.

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How do benchmarks convert to points?
When you submit measures for the MIPS Quality performance category, each measure is
assessed against its collection type-specific benchmark to see how many points are earned
based on your quality performance. Each quality measure is converted into a 10-point scoring
system, except for:
• The topped-out measures finalized with a 7-point scale,
• Measures that don’t meet data completeness criteria, and
• Measures that either don’t have a benchmark and/or the volume of cases you’ve
submitted is insufficient.
Performance on quality measures is broken down into “deciles,” with each decile having a value
between 3 and 10 points. There is a 3-point floor for measures that can be reliably scored based
on performance for the 2019 MIPS performance period as a result measures in the lowest
deciles cannot get less than 3 measure achievement points. The deciles will be based on
stratified levels of national performance (benchmarks) within that baseline period. We’ll compare
your performance on a quality measure to the performance levels in the national deciles. The
points you earn are based on the decile range that matches your performance level. For
measures with inverse performance rates, such as Measure #1 Diabetes: Hemoglobin A1c Poor
Control where a lower performance rate indicates better performance, decile 10 starts with the
lowest performance rate and decile 1 has the highest performance rate.
If a measure can be reliably scored against a benchmark, then you can earn 3-10 points, except
for the topped-out measures finalized with a 7-point scale.
Reliably scored means that:
• A national benchmark exists.
• The sufficient case volume has been met (>20 cases for most measures; >200 cases for
readmissions).
• The data completeness criteria has been met (meaning at least 60% of possible data is
submitted).
What if a measure I chose doesn’t have a national benchmark?
Quality measures that can’t be reliably scored against a benchmark, or quality measures without
a benchmark, will receive 3 points (assuming the measure meets data completeness) unless a
benchmark can be established with performance period data. If the measure does not also meet
data completeness it will receive 1 point (except for small practices which would receive 3
measure achievement points). This applies to measures across all collection types except for
CMS Web Interface measures and administrative claims measures.

16
Maximum Number of Achievement Points by Collection Type
Your quality performance category score is determined by dividing the points that you receive
for measures (and any bonus points) by the maximum number of achievement points that you
could receive, which will depend on your collection type. The maximum number of achievement
points for different collection types is shown below.

There are 80 available points if you submit your data via the CMS Web Interface, administer the
CAHPS for MIPS survey, and the readmission measure can be calculated for your group or
virtual group.
What if measures are impacted by clinical guideline changes?
Clinical guidelines and protocols developed by clinical experts and specialty medical societies
often underpin quality measures. At times, measure stewards must amend quality measures to
reflect new research and changed clinical guidelines. Sometimes, in rare cases, as a result of
the change in these guidelines that occur during a performance period, adherence to guidelines
in the existing measures could result in patient harm or otherwise provide misleading results as
to good quality care.
If this were to occur for one or more measures, where a measure is impacted by clinical
guideline changes, we will identify the measures on the CMS website.
Clinicians who are following the revised clinical guidelines may still report and submit data on
the impacted measure. However, we will suppress scoring on this measure for the particular
performance period. This is done by not scoring the measure and reducing the total available
measure achievement points in the denominator for the Quality performance category by 10
points for the clinician reporting the measure. In this way, the clinician is held harmless for
reporting this measure until the measure specifications can be updated by the measure
steward.

17
How do we determine applicable quality
measures? Eligibility Measure Applicability (EMA) is:
If you’re collecting quality data via Medicare Part B • Based on evaluation of submitted
claims (small practices only) or MIPS CQMs and measures and determination of clinically
during the data submission period you submit less related measures aligned with specialty
than 6 measures or no outcome or high priority measure sets.
measure, we’ll use the Eligibility Measure • Specific to the collection type (i.e., EMA
Applicability (EMA) process to see if you could have won’t determine that a Medicare Part B
submitted more clinically related measures within the claims submitter had a MIPS CQM
same collection type. available).
• Not applicable for eCQMs, QCDR
If we find that there are no applicable measures for measures, and CMS Web Interface
you, you: collection types. Clinicians, groups and
• Won’t be held accountable for not submitting virtual groups who use these collection
those measures. types in conjunction with Medicare Part B
claims measures or MIPS CQMs will not
• Will have a lower number of maximum points be eligible for EMA.
available in the Quality performance
category.
But, if we see that additional clinically-related measures could have been submitted and weren’t,
your maximum number of points available for the Quality performance category won’t be
reduced.
Measure Bonus Points
What is the end-to-end reporting bonus?
You’ll receive 1 bonus point per measure for reporting your quality data directly from your
CEHRT without any manual manipulation. (Your EHR must be certified to the 2015 Edition by
the last day of the performance period.) This bonus is available to measures reported through
the Direct, Log-in and Upload, and CMS Web Interface submission types. Those bonus points
will be added to your or your group’s or virtual group’s Quality performance category
achievement points (those earned based on performance). End-to-end bonus points will be
added to your Quality performance category achievement points (those earned based on
performance) and are capped at 10% of your Quality performance category denominator.
Note for 2019: If you submit eCQMs, you’ll need to use CEHRT to collect the eCQM data. The
CEHRT used to collect the eCQM data will need to be certified to the 2015 Edition by the last
day of the Quality performance period (December 31, 2019). Therefore, in order for practices to
earn the end-to-end bonus for reporting eCQMs for the 2019 performance period, they will need
to report the latest version of the eCQM extracted from 2015 Edition CEHRT.

18
What is the bonus for submitting additional outcome/high priority measures?
There are bonus points for submitting additional measures including 1 bonus
point for each additional high priority measure, and 2 bonus points for each New for 2019: we
additional outcome and patient experience measure. Bonus points will be revised the
added to your or your group’s/virtual group’s Quality performance category definition of a high
achievement points (those earned based on performance) and are capped at priority measure to
10% of the Quality performance category denominator. include opioid-
related measures.
Beginning in 2019, high priority measure bonus points will not be applied to
measures submitted via the CMS Web Interface.
Please note, that this is separate from the 10% cap on the end-to-end reporting bonus. Bonus
points are added to the Quality performance category achievement points (those earned based
on performance) and can be earned in addition to the bonus points available for end-to end
electronic reporting.
How is the small practice bonus applied in 2019?
The small practice bonus will now be added to the Quality performance category, rather than in
the MIPS final score calculation. Beginning in Year 3 (2019), six (6) bonus points will be added
to the numerator of the Quality performance category for MIPS eligible clinicians in small
practices who submit data on at least 1 quality measure.
Improvement Scoring
For the 2019 performance period we are continuing to provide an opportunity to earn
improvement points. Here, you can earn up to 10 percentage points based on the rate of your
improvement in the Quality performance category from the year before. Bonus points will be
incorporated into your or your group’s/virtual group’s overall Quality performance category
score.
How do we evaluate eligibility for improvement scoring?
You’ll be evaluated for improvement scoring in 2019 when you:
• Participate fully in the Quality performance category for the current performance period
(submit 6 measures/specialty measure set with at least 1 outcome/high priority measure
OR submit as many measures as were available and applicable OR report all measures
in the CMS Web Interface; all measures must meet data completeness requirements);
AND
• Have a Quality performance category achievement percent score based on reported
measures for the previous performance period (Year 2, 2018); AND
• Submit data under the same identifier for the 2 performance periods, or if we can
compare the data submitted for the 2 performance periods.
Please review Appendix E for details on how we’ll compare data across identifiers.

19
How is improvement scoring calculated?
Improvement scoring is calculated by comparing the Quality performance category achievement
percent score from the previous period to the Quality performance category achievement
percent score in the current period. Measure bonus points are not included in improvement
scoring.

Example:
In 2018, a MIPS eligible clinician earned 25 measure achievement points and 2 measure bonus
points for reporting an additional outcome measure.
For the 2019 performance period, the same MIPS eligible clinician earned 33 measure
achievement points and 6 measure bonus points for end-to-end electronic reporting.
• 2018 Quality performance category achievement percent score = 42%
o (25/60)
o Excludes the 2 bonus points
• 2019 Quality performance category achievement percent score = 55%
o (33/60)
o Excludes the 6 bonus points
• The increase in Quality performance category achievement percent score from prior
performance period to current performance period = 13%
o (55% - 42%)
• The improvement percent score is 3.1% which will be added to the percent score earned
for reported measures.
o (13%/42%)*10% = 3.1%
Please note that the improvement percent score cannot be negative and is capped at 10%.

20
Calculating the Quality Performance Category Percent Score
The Quality Performance Category Percent Score is a product of the following equation:

*Total available measure achievement points = # of required measures x 10

The small practice bonus has been moved from a bonus added to the MIPS final score to a
Quality Performance Category Score bonus for 2019. The Quality Performance Category
Percent Score equation for small practices is a product of the following equation:

Facility-Based Measurement Scoring

Beginning with the 2019 performance period, we will identify clinicians and groups eligible for
facility-based scoring. These clinicians and groups may have the option to use facility-based
measurement scores for their Quality and Cost performance category scores.
Facility-based measurement scoring will be used for your Quality and Cost performance
category scores when:
• You are identified as facility-based; and
• You are attributed to a facility with a Hospital Value-Based Purchasing (VBP) Program
score for the 2019 performance period; and
• The Hospital VBP score results in a higher score than MIPS Quality measure data you
submit and MIPS Cost measure data we calculate for you.
Please review Appendix F for a list of the FY 2020 Hospital VBP Program Measures that will be
used for facility-based measurement scoring for the MIPS 2019 performance period.

21
Data Accuracy
CMS believes it is important to ensure the Quality Payment Program is based on accurate and
reliable data. Under MIPS, CMS will validate data on an ongoing basis. MIPS eligible clinicians,
groups, or virtual groups may also be selectively audited by CMS.
If a MIPS eligible clinician, group, or virtual group is selected for audit, they would be required to
comply with data sharing requests, providing all data as requested including primary source
documentation. CMS may reopen and revise a MIPS payment adjustment as a result of the data
validation or auditing process. CMS requires all MIPS eligible clinicians, groups, and virtual
groups that submit data and information to CMS for purposes of MIPS to certify to the best of
their knowledge that the data submitted to CMS is true, accurate, and complete. All MIPS
eligible clinicians, groups, and virtual groups that submit data and information to CMS for MIPS
must retain such data and information for 6 years from the end of the MIPS performance period.

Shaping the Future of Quality

Quality measure development and inclusion
In choosing future quality measures, based on stakeholder feedback, CMS looks for measures
that are:
• Outcomes-based
• Applicable
• Feasible
• Scientifically defensible (MIPS quality measures only)
• Reliable
• Valid at the individual MIPS eligible clinician level
• Demonstrate a performance gap (i.e. has room for improvement, is not topped out)
• Not duplicative of existing measures and activities for notice and comment rulemaking
This means that a recommended list of new MIPS quality measures will be publicly available for
comment for a period of time. CMS will evaluate public comments through the rulemaking
process before making a final selection of new MIPS quality measures. Every year, a final list of
quality measures for MIPS eligible clinicians will be published in the Federal Register no later
than November 1 of the year before the first day of a performance period.
The Quality performance category focuses on measures in the following six domains for future
measure thought and selection:
• Patient safety
• Person and caregiver-centered experience and outcomes
• Communication and care coordination
• Effective clinical care
• Community/population health
• Efficiency and cost reduction

22
Annual Call for Quality Measures
Each year, CMS holds a Call for Measures that allows clinicians and organizations, including
but not limited to those representing MIPS eligible clinicians (professional associations and
medical societies) and other stakeholders (researchers and consumer groups), to submit quality
measures for consideration.

Technical Assistance
We provide no cost technical assistance based on your practice size and location to help you
successfully participate in the Quality Payment Program. To learn more about this support, or to
connect with your local technical assistance organization, we encourage you to visit our Help
and Support page on the Quality Payment Program website.

Resources
• Information regarding the Annual Call for Measures and Activities and the Measures under
Consideration (MUC) list, Measure Applications Partnership (MAP) and Pre-rulemaking.
• The eCQI Resource Center contains information regarding eCQMs
• Medicare Shared Savings Program Benchmarks (Applicable for CMS Web Interface
users)
• MIPS APMs in the Quality Payment Program
For questions, contact the Quality Payment Program at 1-866-288-8292 (TTY 1-877-715- 6222),
available Monday through Friday 8:00 AM-8:00 PM Eastern Time, or via e-mail at
QPP@cms.hhs.gov

Version Control Table

Date Version Notes
02/13/2019 p. 8, 19: Clarified CEHRT requirements
p. 17: Corrected error about inverse measures benchmarks; Decile 10 has the
lowest performance rates
p. 20: Added CMS Web Interface reporting to list of “full participation” options
for Improvement Scoring
12/27/2018 Original posting

23
Appendix A - Summary of Quality Data Submission Criteria for MIPS
Payment Year 2020 and 2021 for Individual Clinicians and Groups

Clinician Submission Criteria* Measure Collection Types (or Measure Sets)

Type
Report at least six measures
Individual
including one outcome measure,
Clinicians
or if an outcome measure is not
available report another high
priority measure; if less than six
measures apply then report on
each measure that is applicable.
Report at least six measures
Groups
including one outcome measure,
and Virtual
or if an outcome measure is not
Groups
available report another high
(non- CMS
priority measure; if less than six
Web
measures apply then report on
Interface)
each measure that is applicable.
Report on all measures includes
Groups
in the CMS Web Interface
(CMS Web
collection type and optionally the
Interface
CAHPS for MIPS survey.
for group of
at least 25
clinicians)
Available
Individual MIPS eligible clinicians select their
measures from the following collection types:
Medicare Part B claims measures (individual
clinicians in small practices only), MIPS CQMs,
QCDR measures, eCQMs, or reports on one of
the specialty measure sets if applicable.
Groups and virtual groups select their measures
from the following collection types: Medicare Part
B claims measures (small practices only), MIPS
CQMs, QCDR measures, eCQMs, or the CAHPS
for MIPS survey - or reports on one of the
specialty measure sets if applicable.
Groups of 16 or more clinicians who meet the
case minimum of 200 will also be automatically
scored on the administrative claims based all-
cause hospital readmission measure.
Groups report on all measures included in the
CMS Web Interface measures collection type
and optionally the CAHPS for MIPS survey.
Groups of 16 or more clinicians who meet the
case minimum of 200 will also be automatically
scored on the administrative claims based all-
cause hospital readmission measure.

* Clinicians would need to meet the applicable data completeness standard for the applicable
performance period for each collection type.

24
Appendix B - Example Assigning Total Measure Achievement and
Bonus Points for an Individual MIPS Eligible Clinician Who Submits
Measures Collected Across Multiple Collection Types
In the example below, a single clinician (associated with a practice that has 15 or fewer clinicians
so they meet the definition of a small practice) reported a total of 12 quality measures through
multiple collection types:
• 3 MIPS CQMs
• 4 Medicare Part B claims measures
• 5 eCQMs
This table explains which of these measures will contribute to the clinician’s quality performance
category score, and why (or why not).
Measure Six Scored High-Priority Incentive for
Achievement Measures Measure Bonus CEHRT
Points Points Measure Bonus
Points
MIPS CQMs
Measure A 7.1 7.1 (Outcome (required
(Outcome) measure with outcome
highest measure does
achievement not receive
points) bonus points)
Measure B 6.2 (points not
considered
because it is
lower than the
8.2 points for the
same claims
measure)
Measure C (high 5.1 (points not 1
priority patient considered
safety measure because it is
that meets lower than the
requirements for 6.0 points for the
additional bonus same claims
points) measure)
Medicare Part B Claims
Measure A 4.1 (points not No bonus points
(Outcome) considered because the
because it is MIPS CQM of
lower than the the same

25
 7.1 points for the measure
same MIPS satisfies
CQM) requirement for
outcome
measure
Measure B 8.2 8.2
Measure C 6.0 6.0 No bonus
(High priority (Bonus applied
patient safety to the MIPS
measure that CQMs)
meets
requirements for
additional bonus
points)
Measure D 1.0 (no high priority
(outcome bonus points
measure <50% because below
of data data
submitted) completeness)
EHR (direct submission using end-to-end) Reporting that
meets CEHRT
/bonus point
criteria
Measure E 5.1 5.1 1
Measure F 5.0 5.0 1
Measure G 4.1 1
Measure H 4.2 4.2 1
Measure I (high 3.0 (no high priority 1
priority patient bonus points
safety measure because below
that is below case minimum)
case minimum)
35.6 1 (below 10% 5 (below 10%
cap) cap)
Quality
Performance (35.6+1+5) / 60 =
Category Score
Prior to
Improvement 69.33%
Scoring

26
Appendix C - Summary of Data Completeness Requirements and
Performance Period by Collection Type for the 2020 and 2021 MIPS
Payment Years
Collection Type Performance Period Data Completeness
Jan 1- Dec 31 60 percent of individual MIPS eligible clinician’s, or
Medicare Part B claims
group’s Medicare Part B patients for the
measures
performance period.
Jan 1- Dec 31 100 percent of individual MIPS eligible clinician’s
Administrative claims
Medicare Part B patients for the performance period.
measures
Jan 1- Dec 31 60 percent of individual MIPS eligible clinician’s, or
QCDR measures, MIPS
group’s patients across all payers for the
CQMs, and eCQMs
performance period.
Jan 1- Dec 31 Sampling requirements for the group’s Medicare Part
CMS Web Interface
B patients: populate data fields for the first 248
measures
consecutively ranked and assigned Medicare
beneficiaries in the order in which they appear in the
group’s sample for each module/measure. If the pool
of eligible assigned beneficiaries is less than 248,
then the group would report on 100 percent of
assigned beneficiaries.
Jan 1- Dec 31 Sampling requirements for the group’s Medicare Part
CAHPS for MIPS survey
B patients.
measure

27
Appendix D: Quality Performance Category: Scoring Measures
Measure Description
Type
For the 2018 and 2019 MIPS
Class 1
performance period:
• Measures that can be scored
based on performance.
• Measures that were submitted or
calculated that met the following
criteria:
• (1) Has a benchmark;
• (2) Has at least 20 cases; and
• (3) Meets the data completeness
standard (generally 60 percent.)
For the 2018 and 2019 MIPS
Class 2*
performance period:
• Measures that were submitted
and meet data completeness, but
do not have both of the following:
• (1) a benchmark
• (2) at least 20 cases.
For the 2018 and 2019 MIPS
Class 3**
performance period:
• Measures that were submitted,
but do not meet data
completeness criteria, regardless
of whether they have a
benchmark or meet the case
minimum.
Scoring Rules
For the 2018 and 2019 MIPS
performance period:
• 3 to 10 points based on
performance compared to the
benchmark.
For the 2018 and 2019 MIPS
performance period:
• 3 points
* This Class 2 measure policy does not
apply to CMS Web Interface measures
and administrative claims based
measures
For the 2018 and 2019 MIPS
performance period:
• 1 point except for small practices,
which would receive
• 3 measure achievement points.
Beginning with the 2020 MIPS
performance period:
• MIPS eligible clinicians other
than small practices will receive
zero measure achievement
points.
• Small practices will continue to
receive 3 points.
**This Class 3 measure policy would not
apply to CMS Web Interface measures
and administrative claims based
measures
28
Appendix E – Identifiers Used for Comparing Quality Data in Order to
Measure Improvement Scoring
The table below outlines how we’ll compare data across identifiers for the purposes of Quality
improvement scoring.

Scenario Current MIPS Prior MIPS Eligible for Data

Performance Performance Improvement Comparability
Period Period Scoring
Identifier Identifier (with
score greater
than zero)
No change in Individual Individual Yes Current
identifier. individual score
(TIN A/NPI 1) (TIN A/NPI 1)
is compared to
individual score
from prior
performance
period.
No change in Group (TIN A) Group (TIN A) Yes Current group
identifier. score is
compared to
group score
from prior
performance
period.
Individual is with Individual Group (TIN A) Yes Current
same group but individual score
(TIN A/NPI 1)
selects to submit is compared to
as an individual the group score
whereas associated with
previously the the TIN/NPI from
group submitted the prior
as a group. performance
period.
Individual Individual Individual Yes Current
changes individual score
(TIN B/NPI) (TIN A/NPI 1)
practices but is compared to
submitted to the individual
MIPS previously score from the
as an individual. prior

29
Scenario Current MIPS Prior MIPS Eligible for Data
Performance Performance Improvement Comparability
Period Period Scoring
Identifier Identifier (with
score greater
than zero)
performance
period.
Individual Individual Group Yes Current
changes individual score
(TIN C/NPI) (TIN A/NPI);
practices and is compared to
has multiple Individual highest score
scores in prior (TIN B/NPI) from the prior
performance performance
period. period.
Group does not Group Individual scores Yes The current
have a previous group score is
(TIN A/NPI) (TIN A/NPI 1,
group score compared to the
from prior TIN A/NPI 2, average of the
performance TIN A/NPI 3, scores from the
period. etc.) prior
performance
period of
individuals who
comprise the
current group.
Virtual group Virtual Group Individuals Yes The current
does not have group score is
(Virtual Group (TIN A/NPI 1,
previous group compared to the
score from prior Identifier A) TIN A/NPI 2, average of the
performance (Assume virtual TIN B/NPI 1, scores from the
period. group has 2 prior
TIN B/NPI 2) performance
TINs with 2
clinicians.) period of
individuals who
comprise the
current group.
Individual has Individual APM Entity Yes Current
score from prior individual score
(TIN A/NPI 1) (APM Entity
performance is compared to
Identifier) the score of the

30
Scenario Current MIPS Prior MIPS Eligible for Data
Performance Performance Improvement Comparability
Period Period Scoring
Identifier Identifier (with
score greater
than zero)
period as part of APM entity from
an APM Entity the prior
performance
period.
Individual does Individual Individual was No The individual
not have a not eligible for quality
(TIN A/NPI 1)
quality MIPS and did performance
performance not voluntarily category score
category submit any is missing for the
achievement quality prior
score for the measures to performance
prior MIPS. period and not
performance eligible for
period. improvement
scoring.

31
Appendix F - FY 2020 Hospital VBP Program Measures
The table below identifies the FY 2020 Hospital VBP Program quality measures that can be used
for facility-based measurement scoring for MIPS beginning in 2019.
Short Name Domain/Measure Name NQF Performance
# Period

Person and Community Engagement Domain

Hospital Consumer Assessment of Healthcare 0166 January 1, 2018 –
HCAHPS
Providers and Systems (HCAHPS) (including Care (0228) December 31, 2018
Transition Measure)
Clinical Outcomes Domain
Hospital 30-Day, All-Cause, Risk-Standardized July 1, 2015 – June
MORT-30-AMI 0230
Mortality Rate (RSMR) Following Acute Myocardial 30, 2018
Infarction (AMI) Hospitalization
Hospital 30-Day, All-Cause, Risk-Standardized July 1, 2015 – June
MORT-30-HF 0229
Mortality Rate (RSMR) Following Heart Failure 30, 2018
(HF) Hospitalization
Hospital 30-Day, All-Cause, Risk-Standardized July 1, 2015 – June
MORT-30-PN 0468
Mortality Rate (RSMR) Following Pneumonia 30, 2018
Hospitalization.
Hospital-Level Risk-Standardized Complication July 1, 2015 – June
THA/TKA 1550
Rate (RSCR) Following Elective Primary Total Hip 30, 2018
Arthroplasty (THA) and/or Total Knee Arthroplasty
(TKA)
Safety Domain
National Healthcare Safety Network (NHSN) January 1, 2018 –
CAUTI 0138
Catheter-Associated Urinary Tract Infection December 31, 2018
(CAUTI) Outcome Measure.
National Healthcare Safety Network (NHSN) January 1, 2018 –
CLABSI 0139
Central Line- Associated Bloodstream Infection December 31, 2018
(CLABSI) Outcome Measure
Colon and American College of Surgeons—Centers for January 1, 2018 –
0753
Abdominal Disease Control and Prevention (ACS–CDC) December 31, 2018
Hysterectomy Harmonized Procedure Specific Surgical Site
SSI Infection (SSI) Outcome Measure.
MRSA National Healthcare Safety Network (NHSN) January 1, 2018 –
1716
Bacteremia Facility-wide Inpatient Hospital-onset Methicillin- December 31, 2018
resistant Staphylococcus aureus (MRSA)
Bacteremia Outcome Measure

32
 National Healthcare Safety Network (NHSN) January 1, 2018 –
CDI 1717
Facility-wide Inpatient Hospital-onset Clostridium December 31, 2018
difficile Infection (CDI) Outcome Measure
Elective Delivery 0469 January 1, 2018 –
PC-01
December 31, 2018

Efficiency and Cost Reduction Domain

Payment-Standardized Medicare Spending Per 2158 January 1, 2018 –
MSPB
Beneficiary (MSPB) December 31, 2018

33
Appendix G - CMS Web Interface Collection Type Measures for 2019
CMS Web Measure Name Quality Measure
Interface ID Type
Measure ID
Controlling High Blood Pressure 236 Intermediate
HTN-2
Outcome
Depression Remission at Twelve Months 370 Outcome
MH-1
Diabetes: Hemoglobin A1c (HbA1c) Poor Control 1 Intermediate
DM-2
(>9%) Outcome
Falls: Screening for Future Fall Risk 318 Process
CARE-2
Breast Cancer Screening 112 Process
PREV-5
Colorectal Cancer Screening 113 Process
PREV-6
Preventive Care and Screening: Influenza 110 Process
PREV-7
Immunization
Preventive Care and Screening: Tobacco Use: 226 Process
PREV-10
Screening and Cessation Intervention
Preventive Care and Screening: Screening for 134 Process
PREV-12
Depression and Follow-Up Plan
Statin Therapy for the Prevention and Treatment of 438 Process
PREV-13
Cardiovascular Disease

34